Endoscopic ear surgery - a complement to microscopic ear surgery

[Experiences with endoscopic ear surgery of a German tertiary hospital for otolaryngology]

BACKGROUND

The aim of this article is to report on the integration of endoscopic ear surgery (EES) into daily clinical practice.

MATERIAL AND METHODS

In a monocentric prospective study, the endoscopy unit was set up during even weeks over a period of 10 months and the procedure was primarily started endoscopically via a transmeatal approach. In odd weeks, the endoscopy was omitted. A total of 60 procedures in 59 patients were evaluated. Points of comparison were intraoperative vision, incision-suture time, postoperative hearing outcome, and postoperative otoscopic findings.

RESULTS

With the exception of the facial nerve (p = 0.15 Mann-Whitney U‑test), the EES showed significantly improved visualization of all areas in the middle ear. The incision-suture times were similar in both methods. If bimanual placement of an ossicular prosthesis was necessary, the incision-suture time increased disproportionately (MES: 57.18 ± 9.7 min, EES: 76.83 ± 24.99 min; p = 0.019, *). There were no statistically significant changes related to hearing outcomes when comparing EES with the microscopic technique. There were no postoperative complications in the EES surgery group.

CONCLUSION

Integration of EES proved to be successful and advantageous in a real patient collective at this location.

[Experience of laser myringoplasty in children with juvenile ideopathic arthritis]

Surgeons' dissatisfaction with the surgical treatment for tympanic membrane perforations results leads to the constant improvement of the surgical technique and the emergence of new techniques. Difficulties arise in the surgical treatment of rheumatological patients treated with immunosuppressive drugs due to the high potential risk of postoperative complications. The most promising direction in this cohort of patients can be considered the use of laser exposure techniques under endoscopic control. The experience of performing endoscopic laser myringoplasty in 9 children aged from 6 to 16 years (mean age 10±3 years) with tympanic membrane perforation up to 6 mm in diameter and juvenile idiopathic arthritis treated with methotrexate and tocilizumab is presented. The effectiveness of the studied technique in relation to the closure of perforation of the tympanic membrane was 66.7%. Considering that in children, reconstructive ear surgery is considered less effective than in adults, and the presence of chronic systemic rheumatoid disease and immunosuppressive therapy are risk factors for recurrence of perforation after tympanoplasty, these results can be considered successful. The presented method is promising in this cohort of patients for the restoration of small tympanic membrane defects. However, further research is needed.

The study of otoendoscopic tympanoplasty (type I)

BACKGROUND

With the development of otoendoscopic surgery technology and the update of equipment, more and more otoendoscopic tympanoplasty are carried out.

OBJECTIVES

To investigate application of otoendoscopic tympanoplasty.

METHODS

Seventy-six patients with tympanic membrane perforation were randomly enrolled into otoendoscopic group (OP, n = 38) and microscope group (MP, n = 38). We compared two-group patients using operative time, intraoperative blood loss, healing of postoperative perforations, and degree of postoperative hearing improvement.

RESULTS

Average operation time was statistically significant shorter in the OP than the MP (p < .05); the intraoperative blood loss in the OP was significant less than MP (p < .05); after postoperative follow-up, the healing rate of tympanic membrane perforation was 92.11% in the OP compared to 89.47% in the MP. However, there was no statistically significant difference in the two groups (p > .05). There were no statistically significant differences between the preoperative and postoperative air and bone conduction thresholds in the two groups (p > .05).

CONCLUSIONS

Otoendoscopic tympanoplasty is a minimally invasive operation but with similar effects as compared to microscopic one. But the operation time and intraoperative blood loss in the OP were significantly better than those in the MP, thus it is a safe, effective and easy to be operated in clinical practice.

Two-handed endoscopic ear surgery: Feasibility for stapes surgery

OBJECTIVE

Endoscopic ear surgery is becoming an increasingly popular approach. Our aim in this study is to evaluate the feasibility of the two-handed endoscopic technique for stapes surgery, which has its own unique steps.

METHODS

Patients who underwent two-handed endoscopic stapes surgery between September 2017 and February 2018 were included in this study. Preoperative and postoperative pure tone averages and air bone gaps, intraoperative complications were recorded. All procedures were performed under hypotensive general anesthesia by the same surgeon using 0° rigid endoscopes of 2.7-mm diameter, 14-cm length with an endoscope holder.

RESULTS

Seven endoscopic two-handed stapes surgery were performed between September 2017 and February 2018. Of these, six patients were operated entirely endoscopically because one patient was found to has perilymph gusher and converted to microscopic surgery. There were no intraoperative tympanic membrane injuries, facial nerve paresis or sensorineural hearing losses. The average preoperative ABG of patients who underwent fully endoscopic surgery was 31.3 dB, and the postoperative ABG closed up to 9.6 dB.

CONCLUSIONS

Adoption of the two-handed technique during endoscopic stapes surgery ensures the surgeon benefits from the advantages of endoscopy while overcoming the disadvantages of the one-handed technique.

A Novel Three-Dimensional Robot Arm Steered Camera for Ear Surgery

ABSTRACT

Ear surgery requires magnified imaging of anatomical structures from its beginning to achieve safe and successful surgical outcomes. The historical evolution of magnification in otology has developed from monocular to binocular, and to three-dimensional and even to digital in modern times. Current technological advancements pursue high-quality visualization for the best surgical outcomes but also ergonomic for surgeons. Here, we evaluated the usability of such new technology in common otological surgeries like cochlear implantation and stapedectomy for the first time in patients. A three-dimensional camera mounted to a robot arm has hands-free control by goggles worn by the surgeon on a head mount. The camera at a distance of the patients but can also be draped in a sterile way that it forms a barrier tent between patient and surgical personnel in the theatre. The main reason to evaluate the feasibility of this new exoscope was driven by COVID-19 obligate measures for elective surgery such as hearing restoration. This new technology can be considered an important advantage for the surgeons working in microsurgery to perform their elective operations without aerosolization of the drill rinsing water possibly containing contaminated tissue. From a subjective point of view, the image quality is equivalent to conventional microscopes to provide safe otologic surgery.

[Endoscopic ear surgery in Germany : Survey on the current situation and an international comparison]

BACKGROUND

Endoscopic ear surgery (EES) has become firmly established internationally. In Germany this technology is controversially discussed and used very differently. Therefore, a survey was carried out on the availability, indications, contraindications, and future significance of EES.

METHODS

A questionnaire with 20 questions was sent to 141 German university and central departments of otorhinolaryngology, head and neck surgery. The results are discussed on the basis of current literature retrieved in a search of PubMed and Google Scholar.

RESULTS

The response rate was 32% (45 clinics). Of these respondents, 27 clinics (60%) stated that EES was usually carried out as an accompanying measure. Only one clinic performed ear surgery endoscopically alone. In cases of intraoperative bleeding, mastoid drilling, or if bimanual work was required, the surgeons switched to microscopic ear surgery (MES). The most common indications for EES were tympanoscopy, cholesteatoma, retraction pockets, and interventions on the tympanic membrane and external auditory canal. The necessary resources for EES were estimated to be higher than for MES in 49-50% of the responding clinics. Tragus cartilage dominated as the graft material for reconstruction in EES clinics, at 78%. Only 4 of 45 responding clinics rated the future significance of ESS in Germany as high.

CONCLUSION

Although EES is used in Germany, only few ENT clinics use it extensively. Reservations relate to one-handed working, drilling, management of bleeding, and the expected high resource demand. Thus, EES in Germany is often performed as an accompanying procedure, with switching between EES and MES.

Classification of the Chorda Tympani: An Endoscopic Study

OBJECTIVES

To determine the ability of preoperative computed tomography (CT) to predict the variable surgical anatomy of the chorda tympani nerve (CTN) based on endoscopic tympanotomy.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

We identified 192 ears of 162 patients who underwent transcanal endoscopic ear surgery from August 2013 to June 2018. Patients with middle ear malformations, revision surgeries, myringoplasty, and cholesteatoma involving the CTN were excluded.

INTERVENTIONS

An intraoperative endoscopic image depicting the chorda tympani was selected for each patient and classified into one of five types. Preoperative CT images were analyzed to match the pictorial classification.

MAIN OUTCOME MEASURES

The visible tympanic segment of the chorda tympani was classified into the following five types: external auditory canal (EAC), detached, attached long, attached short, and ultrashort.

RESULTS

A total of 128 ears from 101 patients ranging in age from 2 to 81 years were enrolled. The EAC, detached, attached long, attached short, and ultrashort types of CTN were found in 7 (5.5%), 6 (4.7%), 84 (65.6%), 18 (14.0%), and 13 (10.2%) patients, respectively. The presence of the EAC type could be predicted by preoperative CT while the other four types could be predicted by binning into two groups, with a sensitivity of 0.61 and specificity of 0.72.

CONCLUSION

The variable anatomy of the chorda tympani nerve can be classified into five major groups based on endoscopic tympanotomy.

Improving Microscopic Imaging in Otology and Neurotology

OBJECTIVE

Due to the microscopic nature of otologic surgery, photographic image quality suffers from an inherent inability to maintain all the planes of surgery in focus under binocular microscopy. Our goal was to perform simple editing techniques to create improved imaging for educational and research purposes in the field of Otology and Neurotology.

PATIENTS/DESIGN

The study was a proof of concept performed with series of cases including patients undergoing transmastoid and transcanal otologic surgery over time period of December 1, 2018 to March 1, 2019 at an academic medical center. The Zeiss OPMI Pentero 800 operating microscope was used with a camera capturing 2.1 megapixel, 1098 × 1080 resolution images.

INTERVENTION

We created a systematic protocol for capturing images of multiple focal lengths during each surgery. With the image-editing technique of focus-stacking, multiple images of varying focal length, were spliced together to produce high-quality and high-fidelity composite images rendered using the Adobe Photoshop (San Jose, CA).

OUTCOMES

Subjective comparisons of pre and post photo-edited photographs.

RESULTS

Composite, focus-stacked images with comparison to unedited microscopic pictures are reviewed in the manuscript.

CONCLUSION

We describe a simple and objectively practical method for improving the quality of medical imaging in the field of Otology/Neurotology. To achieve this enhanced image quality, a relatively expeditious and reliable photographic protocol can be used for image capturing and editing, requiring little to no additional training for a physician in the field.

Transcanal Endoscopic Retrograde Mastoidectomy for Cholesteatoma: A Prospective Study

OBJECTIVES

To evaluate the feasibility, morphological, and functional outcomes of endoscopic retrograde transcanal mastoidectomy.

STUDY DESIGN

Prospective study.

SETTINGS

Tertiary Referral Hospital.

MATERIALS AND METHODS

We analyzed 31 patients with a diagnosis of chronic otitis media with cholesteatoma that extended to the mastoid cavity who underwent endoscopic transcanal retrograde canal wall down mastoidectomy under general anesthesia. The tympanic membrane and posterior canal wall reconstruction were done using the tragal cartilage palisade technique reinforced with perichondrium. Morphological and functional results were reported in the follow-up of a minimum of 1 year. The graft uptake was also compared with the presence of granulations and discharge status.

RESULTS

Graft uptake and disease-free conditions were achieved in 21 of 24 patients, that is, 87.5%, and 3 patients required revision surgery. The graft uptake rate was not affected by the presence of granulation tissues and discharge. The hearing was improved after the surgery, which was statistically significant.

CONCLUSION

Endoscopic retrograde mastoidectomy is a new technique to deal with cholesteatoma with excellent results. It is more functional, ideal for sclerotic mastoid, allows faster wound healing, has excellent outcomes, and is a minimally invasive procedure that avoids postauricular incision and tissue dissection. Because the set up for the surgery costs less, it holds a promising future for the developing countries.

[Transcanal endoscopic middle ear surgery in children with chronic suppurative otitis media]

Otomicroscopic surgery remains the gold standard in the surgical treatment of patients with CHS. Endoscopic ear surgery is gaining more and more importance as an adjunct to microsurgery. Recently, thanks to the resolution of the endoscopic technique, endoscopic surgery can be used as an independent method. This article presents the results of endoscopic tympanoplasty, endoscopic removal of the tympanic cholesteatoma, performed on the basis of the otorhinolaryngology department of the Morozov Children's City Clinical Hospital. Research has shown that transcanal endoscopic surgery is an effective alternative to traditional otomicroscopic surgery. Advantage in minimal impact and improved visualization of all quadrants of the tympanic membrane, the anterior tympanomeatal angle of the NSP, and structures of the middle ear.

The application of a 70° endoscope in performing transcanal middle ear surgery

BACKGROUND

Endoscopes increase the expediency of transcanal middle ear surgery. However, the application of a 70° endoscope is limited and seldom discussed, mainly because of its large angle. We introduce our experiences with the 70° endoscope in transcanal middle ear surgery.

METHODS

This is a retrospective chart review of 127 patients with chronic otitis media who underwent middle ear surgery performed by the senior author in 2016 at a tertiary referral center. The types of eardrum perforation were classified as central, inferior, posterior, or anterior according to the main location of the hole. The demographics, surgical pictures, and operative records were reviewed.

RESULTS

In 15 ears of the 127 patients, the ossicles were recognized directly by a microscope. In another 112 ears, the ossicles could not be identified under a microscope. Without elevating the tympanomeatal flap, the ossicles could be recognized in 72 of these 112 ears with endoscopes, especially the 70° endoscope. In 35 of these 112 ears, an incision to extend the drum perforation or creation of a small tympanomeatal flap in the posterior-superior canal was made to observe the ossicles. However, 5 of these 112 ears were still noted to have a narrow and/or curved ear canal and preoperatively needed to undergo endaural incisions. Among the other 122 patients who first underwent attempted transcanal surgery, 15 ears changed to endaural incisions. The drum perforations were repaired directly through the perforation in 107 ears via the transcanal route. One year after surgery, the air-bone gap closure was 16.0 ± 11.8 dB, and the graft take rate was 91.3%.

CONCLUSION

With the help of a 70° endoscope, we can use the transcanal transperforation route to evaluate and reconstruct drum perforations and ossicular chains in appropriate patients. Hence, normal tissue injuries to the ear canal can be minimized.

Endoscopic versus microscopic type-I cartilage tympanoplasty for anterior perforation - a comparative study

BACKGROUND

Chronic otitis media with anterior perforation is a challenging condition to treat with a microscope especially if the canal is narrow or has overhang. The endoscope provides the advantage of wide-angle view and transcanal access avoiding postauricular approach and canaloplasty.

OBJECTIVE

To compare the anatomical, functional outcomes, and surgical duration between endoscopic and microscopic type-I tympanoplasty performed for anterior perforation.

MATERIALS AND METHODS

A comparative study was conducted. The two groups, the microscopic (MT) and the endoscopic (ET) were created with 50 cases each and underwent type-I tympanoplasty. Results were evaluated at a minimum follow-up of 12 months.

RESULTS

The graft uptake rate in MT and ET was 81.8% and 91.3% respectively and was not statistically significant. The mean operative time for MT and ET was 68.68 ± 18.79 min and 61.24 ± 11.18 min respectively which was significant (p-.003). Endoscopic tympanoplasty significantly saved time. The difference in hearing outcomes was highly significant within the groups but not between the groups.

CONCLUSION AND SIGNIFICANCE

The endoscopic tympanoplasty offered superior visualization avoiding postauricular incision and canaloplasty, with morphological and functional outcomes comparable to microscopic tympanoplasty. It offers significantly faster completion of procedure and provides minimally invasive surgery.

Introducing the High-definition 3D exoscope in ear surgery: preliminary analysis of advantages and limits compared with operative microscope

PURPOSE

The aim of this study was to evaluate the potential of 3D exoscope (EX) in selected ear procedures assessing if this new technology could be an improvement in the field of ear surgery.

METHODS

A case series of consecutive patients surgically treated with a post-auricular approach using EX was retrospectively compared with a similar previous series treated with operating microscope (OM). Patient demographics, indications for surgery, procedure type, complications, operating room setting time (ORst), operative time, adequacy of visualization, image quality, ergonomics aspects, instrument usability, and technique as a teaching tool were investigated. Thirteen patients were included in each group. Surgical procedures in EX group were nine tympanoplasties with mastoidectomy, 1 mastoidectomy for acute complicated mastoiditis, 1 revision miringoplasty, and 2 cochlear implants. Same types of procedures were enrolled in OM group.

RESULTS

No statistically significant difference was found between the two groups concerning ORst and operative time. In EX group, one complication occurred--a middle cranial fossa cerebrospinal fluid leak. Advantages of EX were lightness, maneuverability and compactness, less need of endoscopy during surgery, and teaching potential. Limits were a need of a large surgical corridor and the bright structures rendering in high magnification.

CONCLUSION

EX resulted safe and efficient in treating diseases of the middle ear in post-auricular approaches. To date, EX advantages are not enough to abandon the OM, and it can be considered as an additional, innovative tool to be added to ear surgical equipment.

Comparative study of endoscopic and microscopic tympanoplasty performed by a single experienced surgeon

PURPOSE

The use of endoscopes in otologic procedures has been increasing worldwide. This study aimed to compare the efficacy of microscopic tympanoplasty (MT) and endoscopic tympanoplasty (ET) for tympanic membrane and middle ear surgery.

MATERIALS AND METHODS

We retrospectively analyzed 81 patients who underwent MT (n = 44) and ET (n = 37) for chronic otitis media with tympanic membrane perforation performed by a single surgeon between January 2013 and September 2019. The hearing outcomes, graft success rate, complications, operation time and hospital stay, and cost-effectiveness were recorded and compared between groups. Hearing outcomes were determined by pure tone audiometry. Cost-effectiveness was determined by the operation cost and total cost.

RESULTS

There was no significant difference between the MT and ET groups regarding demographic characteristics, with the exception of the male:female ratio. There was no significant difference in the pre- and postoperative air conduction, bone conduction thresholds, and air-bone gap values between the two groups, but a significant audiologic improvement was observed in both groups (p < 0.05). In terms of recurrence of tympanic membrane perforation, postoperative otorrhea, and discomfort symptoms, there was no significant difference between groups (p > 0.05). The operation time and hospital stay were shorter in the ET group than in the MT group (p < 0.05). There were no significant differences in operation cost between the two groups (p > 0.05), but the total cost was significantly lower in the ET group than the MT group (p < 0.05).

CONCLUSION

ET is as safe and medically efficacious as conventional MT, shortens the operation time and hospital stay, and is cost-effective.

Investigating the learning curve in endoscopic compared to microscopic myringotomy and ventilation tube insertion

OBJECTIVE

Rate of learning is often cited as a deterrent in the use of endoscopic ear surgery. This study investigated the learning curves of novice surgeons performing simulated ear surgery using either an endoscope or a microscope.

METHODS

A prospective multi-site clinical research study was conducted. Seventy-two medical students were randomly allocated to the endoscope or microscope group, and performed 10 myringotomy and ventilation tube insertions. Trial times were used to produce learning curves. From these, slope (learning rate) and asymptote (optimal proficiency) were ascertained.

RESULTS

There was no significant difference between the learning curves (p = 0.41). The learning rate value was 68.62 for the microscope group and 78.71 for the endoscope group. The optimal proficiency (seconds) was 32.83 for the microscope group and 27.87 for the endoscope group.

CONCLUSION

The absence of a significant difference shows that the learning rates of each technique are statistically indistinguishable. This suggests that surgeons are not justified when citing 'steep learning curve' in arguments against the use of endoscopes in middle-ear surgery.

Can endoscopic ear surgery replace microscopic surgery in the treatment of acquired cholesteatoma? A contemporary review

Acquired cholesteatoma leads to significant morbidities while current surgical options remain a challenge. The principles of surgery include complete removal of disease, prevention of recurrence, and restoration of hearing function when possible. Traditionally, this has been performed using microscopes; however, a novel technique using endoscopes offers a new perspective on our understanding of anatomy, pathogenesis and surgical approaches. In recent years, various studies have demonstrated good outcomes with transcanal endoscopic ear surgery (EES) in cholesteatoma surgery. Nevertheless, the use of EES is not universal and remains controversial due to the efficacy of microscopes, specific limitations of endoscopes and the need to learn new skills. This review focuses on recent advances in EES for the treatment of acquired cholesteatoma, benefits, current challenges, and a discussion on the indications and contraindications of EES.

Patterns of middle-ear cholesteatoma and implications for surgical approach

OBJECTIVES

Understanding the pattern of middle-ear cholesteatoma becomes pertinent with the rise of endoscopic surgery as surgeons decide on the optimal approach to visualise and extirpate disease. With modifications to the Telmesani attic-tympanum-mastoid staging system, this study aimed to evaluate the commonest patterns of middle-ear cholesteatoma and their implications for surgical approach.

METHODS

A retrospective study was conducted in a single tertiary institution in Singapore. All patients undergoing cholesteatoma surgery between January 2012 and June 2015 were included. Staging of cholesteatoma was based on clinical assessment corroborated by radiological findings.

RESULTS

Out of the 55 ears included, 98.2 per cent had cholesteatoma involving the attic. The disease extended into the mastoid antrum and beyond in 43 cases (78.2 per cent). The facial recess and/or sinus tympanum was affected in 26 cases (47.3 per cent).

CONCLUSION

The majority of cholesteatoma cases present with extensive attic disease and significant mastoid involvement. In these cases, endoscopes may be best suited to adjunctive rather than exclusive use in surgery.

Endoscopic versus external dacryocystorhinostomy: temporal and regional trends in the United States Medicare population

Purpose: Endoscopic surgeries, such as dacryocystorhinostomy (DCR), are increasingly performed for orbital and lacrimal conditions. This study describes and compares recent trends in endoscopic DCR with open, or external, DCR in the United States (US). Methods: Medicare-Part-B National Summary data files were analyzed from 2000 to 2015 for temporal and geographic trends in endoscopic and external DCR. Medicare Physician and Other Supplier public use files detailing provider information were collected and analyzed from 2012 to 2015. Results: Between 2000 and 2015, the number of external DCRs remained relatively unchanged (8008 to 7086, -0.7% average annual growth), while the number of endoscopic DCRs steadily increased (881 to 1674, 4.6% average annual growth). The greatest number of endoscopic DCRs were performed in the South Atlantic region, whereas the Mountain region had the greatest number per capita. From 2000 to 2015, the average payment per procedure for external DCR was $526.63, compared with $512.45 for endoscopic DCR. Of endoscopic DCRs performed from 2012 to 2015, 831 (79%) were performed by Ophthalmology, 184 (18%) were performed by Otolaryngology, and the remainder by other subspecialties. Conclusions: The number of endoscopic DCR surgeries increased over the last 15 years while the number of external DCR surgeries remained stable and continued to surpass endoscopic procedures. While ophthalmologists perform the overwhelming majority of endoscopic DCR, otolaryngologists are performing a growing number.

Complications in Endoscopic Ear Surgery

OBJECTIVE

The aim of this study was to examine the premise that endoscopic ear surgery (EES) is associated with a low rate of complications (intraoperative and postoperative).

STUDY DESIGN

Retrospective review at two institutions.

SETTING

Tertiary referral center.

PATIENTS

The study included 825 patients who underwent exclusive EES between 2008 and 2016 at the Otorhinolaryngology-Head and Neck Surgery Department of Modena University Hospital, and between 2014 and 2016 at the Otorhinolaryngology-Head and Neck Surgery Department of Verona University Hospital.

INTERVENTIONS

Exclusive endoscopic ear surgery between 2008 and 2016 (tympanoplasties, second look or revision tympanoplasties, myringoplasties, stapedoplasties, canalplasties, ossiculoplasties, and exploratory tympanotomies). All surgical procedures were performed by two experienced surgeons.

MAIN OUTCOME MEASURE

For each procedure, intraoperative, and early and delayed postoperative complications were evaluated.

RESULTS

The most common ear pathologies for which patients were sent for EES were cholesteatoma (33.6%), chronic otitis media (36.3%) and otosclerosis (26.8%). There was no case of major intraoperative complications such as injury to the dura or vascular structures. We observed minor intraoperative complications in 4.1% of the cases. Only 1.3% of patients experienced early postoperative complications. Delayed complications affected less than 1% of the cohort.

CONCLUSIONS

Data from this study confirm the safety of the endoscopic technique, with very low complication rates, indicating that EES is a reliable therapeutic option, in particular, for tympanoplasties, myringoplasties, and stapedoplasties, as well as second look procedures. We have reported our experience with EES morbidity so that it can be compared with data from other centers using the same surgical technique.

The first Malaysian experience on totally endoscopic ear surgery

Introduction:

Totally endoscopic ear surgery (TEES) is defined as exclusive application of endoscope transcanally in otologic surgery. This study is aimed to highlight indications and ear pathologies for TEES. In addition, intraoperative, early postoperative and delayed postoperative complications of TEES will be also described in this study.

Methodology:

This is a retrospective study of TEES performed by a single experienced and trained otologist in endoscopic ear surgery in a single institution between 1 July 2014 and 31 June 2018. A total of 43 patients were recruited in this study. Sociodemographic information, indications for TEES, ear pathologies, type of surgery performed and complications of TEES were analyzed.

Results:

The indications for TEES comprised middle ear lesion (65.1%), followed by second look surgery (14.0%), external auditory canal lesion (11.6%) and internal acoustic meatus lesion and surgery for conductive hearing loss which were 4.7%. Various external auditory canal pathologies encountered for TEES were ear canal osteoma (4.7%), acquired ear canal stenosis (2.3%) and tumor (4.7%). Regarding middle ear pathologies, limited atticoantral cholesteatoma accounted for most of the cases, 46.5%. Other middle ear lesions included adhesive otitis media (14.0%), recurrent cholesteatoma (14.0%), tumor (4.7%), otosclerosis (2.3%) and ossicular discontinuity (2.3%). Internal acoustic meatus lesion constituted 4.7% of cases. Some 4.7% of cases developed intraoperative complications, while early and delayed complications were 7.0%.

Conclusion:

TEES is a feasible surgical technique for diverse ear pathologies in the otologic specialty. It is also proven to be safe with good surgical outcomes.

[The role of the endoscopic assistance in the surgical treatment of the children presenting with chronic suppurative otitis media and cholesteatoma]

The present study was designed to elucidate the possibilities for the application of angled endoscopes in the sanation of those compartments of the middle ear which are difficult to access for visual control with the use of a microscope, such as the retrotympanic structures (e.g. tympanic and facial retraction pockets), anterior epitympanum, etc. To this effect, we have undertaken the analysis of the results of surgical interventions on the children presenting with chronic suppurative otitis media and concomitant cholesteatoma. A total of 59 primary operations and 35 secondary ones were performed to treat recurrent cholesteatoma. In 41 cases, the surgical intervention was carried out without the endoscopic assistance whereas in the remaining 53 ones the microscopic observation of the difficult-to-access compartments of the middle ear were supplemented by the application of an angled endoscope. Whenever residual portions of cholesteatoma were identified, they were removed under the endoscopic control. The algorithm for the endoscopic assistance during such operations has been proposed, its advantages and limitations are considered. It is concluded that the combination of microscopic and endoscopic techniques for the examination of and operation on the middle ear creates the conditions for the more reliable (in comparison with the traditional otomicroscopic methods) removal of the residual cholesteatoma tissues and thereby allows to reduces the risk of development of residual cholesteatoma from 25% to 13.5%. The results of the present study have demonstrated the necessity of development of a universal approach to the identification of the clinically significant manifestations of chronic suppurative otitis media and cholesteatoma.

Endoscopic ear surgery in the ear camp setting; forward thinking or folly?

Background:

Endoscopic ear surgery is becoming an accepted technique in otological surgery, in the management of chronic otitis media.

Methods:

The technique was introduced to the humanitarian care setting of an ear camp in Nepal to consider the appropriateness of the technique in this type of clinical setting.

Results:

Fifteen cases of myringoplasty were successfully completed.

Conclusion:

The apparent advantages of the endoscopic approach over the traditional microscopic one were the ease of transporting the equipment and the optimal view obtained of the tympanic membrane. The ability for pathology and operative technique to be observed equally well by the surgeon and local staff was helpful for teaching, and enables a move towards self-sufficiency of care. Easy image capture also has potential for remote telemedicine applications.